Provider Demographics
NPI:1801220785
Name:TARANGO, JACK III (MASTERS)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:TARANGO
Suffix:III
Gender:M
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6413 WHITE TIGER CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-1875
Mailing Address - Country:US
Mailing Address - Phone:310-780-2936
Mailing Address - Fax:
Practice Address - Street 1:570 W CHEYENNE AVE STE 210
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-3983
Practice Address - Country:US
Practice Address - Phone:702-754-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst